By Msgr. Noel C. Burtenshaw

(This is the second in a four-part series.)

Joan Walker’s mother is in the hospital. The old lady, now 75, has broken her hip. She needs nursing home care. Her doctor tells Joan, who has a job and a family of her own, that her mother will receive up to 100 days of recuperation in the nursing home under Medicare.

Joan believes her doctor. But she should not. He may be giving her wrong information. There was a time, not too long ago, when the doctor was perfectly correct about Medicare. Now he is probably wrong.

Patricia Sheppard is administrator of the Americana Healthcare Center on North Decatur Road in Decatur. Her center, which houses about 100 senior citizens, has watched the Medicare scene change drastically for senior citizens in the recent past. “Families need to be careful,” says Mrs. Sheppard, who is a parishioner at St. John Neumann Church. “Doctors tell them one thing. Then they find out another.”

In the case of Joan Walker’s mother, she may well qualify for Medicare in the nursing home for the first 20 days. But then on the 21^st day, Medicare payments must be accompanied by private co-insurance. Medicare assistance may stop altogether if the patient gets to a point of wellness that the government agency judges her not in need of skilled care. Then what?

“Well, if Joan has the private insurance to continue her mother’s stay in the home,” says Patricia Sheppard, “she may stay. Otherwise after due notice she has to take her home.”

What about Medicaid, will that kind of assistance take over the lady? The answer is no, unless her income is somewhere below $925 a month. “And they are strict about that sum,” says Mrs. Sheppard. “If they even have a life insurance policy whose cash value is more than $1,700 qualification for Medicaid is impossible.”

So Joan takes her mother home. She will receive no help from Medicare unless the lady needs skilled nursing care at home. Joan must work. It is almost impossible to get someone to stay with the old lady. The problems are enormous.

Let us just pause here and remember that Joan, her mother and all the family have been paying into the Medicare system for years. Now it is useless for this type of senior citizen who may need it most.

The Americana Healthcare Center is one of the better and more expensive nursing homes that is available. So Joan may look around at other homes that are less expensive. “It is very difficult to operate a nursing home today,” says Patricia Sheppard. “The problem, of course, is help. Homes pay low salaries in an effort to keep costs down. But it is a struggle to run a good home and at the same time hire consistently good help. The work is hard. There are better jobs.”

An Atlanta television station revealed just last week that many abuses were taking place in an inexpensive nursing home in Roswell. “There was an uproar,” says Michele McClave, who is program coordinator for the Long-Term Care Ombudsman of Metropolitan Atlanta, an organization funded by the federal government and the state to watch for seniors’ rights. “But the families are caught in a difficult position. Even though things are bad in some of these homes, where will they turn if the home is closed. Very often it is a long time before the problem is reported or looked into.”

The arena of Medicare, Medicaid and seniors who need nursing care sounds like a muddled mess and it is. The problem is that benefits were very liberal initially, says Patricia Sheppard. “Now we see that the system can’t afford the promises once made. It needs attention.”

Joan Walker will have to take care of her mother in the home. There are personal care homes available where senior citizens will be accommodated, but Medicare will not pay for this kind of care. If Joan’s mother is to go to such a home, then the old lady must be able to take care of herself to a certain degree. She must be able to make her own bed and to be mobile enough to go to meals, bathe, etc. Otherwise she must leave. The average cost to Joan for a personal care home is $10,000 per year. It will cost more if transportation to doctor’s offices is needed.

Let us suppose that Joan’s mother cannot qualify for Medicare, but because of her low income qualifies for Medicaid, then what? (Let us remember if you have more than $925 per month in income, pension, etc. and have more than $1,700 in value, savings, etc., you cannot qualify for Medicaid.)

The value of Medicaid assistance is set by the state. In some states the value is set high: Florida, for example, is about $78 per day. Georgia is very low, in fact, at $34 per day, it is 48^th lowest in the nation. So Joan must now look for a nursing facility that will take a Medicaid applicant.

“They are there,” says Michele McClave, “and some are good, but some are not. There is neglect at times; for example, there is little recreational activity in these homes. We get 40 to 50 complaints each month from families. We look into them. Many do not want to complain because they are afraid of what they will have to do next.”

Joan’s mother is lucky, she can get around with little help. If she qualifies, she will find a place even if there is a waiting period. “If the senior citizen is what we call “heavy care,” says Michele, “it is more difficult.” Heavy care patients are those who are immobile or need constant watching. They cannot bathe, they need help to use the toilet. It is most difficult to place a senior citizen on Medicaid, who cannot take minimal care of themselves. They may have to wait to find a nursing home willing to consider them. When they are accepted, they must surrender their monthly Social Security check and are given $25 each month to keep for incidentals. It’s not much, all agree, but that’s what the system specifies.

What happens to a senior citizen who is left without family, without money and is found to be incapable of taking care of themselves? “They would be taken to Grady Hospital,” says Michele McClave, “and after receiving medical attention would be placed with Adult Protective Services. This is a state agency which places those with no family, who can no longer care for themselves, in a nursing home of some kind where proper care would be given to them.”

“The total care community is searching for answers,” says Patricia Sheppard. “Some nursing homes are closing. The Medicare people are checking and watching to save money, yet sometimes it seems that the money they spend seeing to it that people qualify would be better spent on the people. The bureaucracy grows. We need more staff to process the forms, they need more to check what we send. The patient keeps getting less. There is no end to it.”

“It is even more difficult now to get those on Medicare into hospitals,” says Mrs. Sheppard. “Senior citizens who used to qualify without question, now don’t qualify for a hospital bed at all. They must have procedures done as an outpatient. This, of course, is a burden on families. Doctors finding it difficult to get Medicare patients into hospitals are beginning to say that they will go back to treating older patients in their homes and letting them die there instead of in the hospital.”

From statements like that it is obvious that progress when connected to governmental red tape very often means regress.

Some nursing homes, to alleviate costs and help their patients remain in treatment, are adding “apartment style” rooms to their facilities. Residents who can care for themselves can use these rooms and still avail themselves of the dining rooms and laundry of the main facility. “It is a way that is being explored,” says Patricia Sheppard, “to help those who cannot afford nursing home care.”

Patricia Sheppard sometimes finds her job to be a heartbreaking one. “You hate to tell them to go, but sometimes there is not choice. They say ‘We have no one at home to care for us.’ Medicare does not care about that situation. If the senior citizen does not qualify, the government will not pay.”

Will it become more manageable in the future? Will the benefits get better and qualification for Medicare become easier? Everyone answers very cautiously. Down the road a struggle is emerging. A greater portion of the population will become senior citizens, over age 65 with real great political power. This scares the government and legislators because they are struggling with a Medicare system that could bankrupt. Will the senior population demand too much and see the system go broke?

No one wants to say that the answer is another system, for example, socialized medicine. At one time this suggestion was the answer many heralded. However, many governmental voices in England have claimed complete failure for socialized medicine in that country, so another answer is being sought.

There is pain and muddle everywhere you look in the present situation. Whatever the answer, this much is sure, many presently paying into the Medicare system, will live to see serious changes made. They may even see the system which presently takes money from paychecks each month disappear. They can only hope that, in time, they will see a better system replace it.